Home Trainer’s Info Request

Name

Phone Email

City State

Zip Code Country

Check the box(es) that relate to your request. Then in the blank space below the questions, please give us the information we need to help you find the resources you are seeking. We will respond promptly.

Equipment and Software
Are you considering a change or upgrade to your current equipment or software? What do you want to change? If you are seeking equipment for the first time, what features are important to you? Who are you considering brain training for, and for what issues?

Trading Post
Please describe the make, model, serial #, months of use, software and accessories.

Family Systems Assessment
Who are the members of the family system (ages, relationships, sex)? What is the living situation? Who are you considering brain training for, and for what issues?

Assessment and Training Plan
Who are you considering brain training for, and for what issues?

Referrals
What are you looking for in a brain training professional? Who are you seeking brain training for, and for what issues? Have you seen a professional before?

        HomeTrainer’s Workshop
Please tell us the size of the group and some dates that would work for you. It would also be helpful to know what issues group members hope to address with brain training.

Other